Future options for the NHS

Notes from Health Matters seminars at Kings College London  on March 1^st 2013 and University College London on April 26^th 2013

Near future:  In the run up to the 2015 general election, the NHS is likely to have:

•  A large part of community services (and some hospital services) provided or managed by the private sector. Mental health services, of which 30% are currently provided by commercial or third sector organisations, are the shape of things to come.
• Clinical Commissioning Groups struggling with rising demand and expectations, and shrinking budgets, with limited powers. Some CCGs will manage these pressures better than others, perhaps changing general practice as they do so, but others will fail to develop services or balance budgets.
• Increased central efforts to manage (and micro-manage) the NHS, and promote service integration as a cost-saving exercise. Provider flux and unachievable targets will undermine these efforts, and top-down management will fail more often.
• More public engagement with the NHS agenda, through both official channels (Health Watch, the Health & Wellbeing Boards) and unofficial ones (campaigns to preserve existing NHS resources & services). The tension between bottom-up accountability and political accountability will increase tensions within the NHS.
• Further shrinkage of publicly-funded social care. Individuals managing their own social care by using the benefits system will be challenged even as political rhetoric emphasises personalisation and personal budgets.
• Instability in the hospital sector, particularly where there is PFI debt. This instability will also arise because of  the inability of the NHS to respond to social and demographic changes (more very old, fewer carers), inherent inefficiencies in hospital organisation, plus declining staff engagement, motivation and confidence. The divide between DGHs and teaching hospitals will widen, and 50 or so Hospital Trusts will not achieve Foundation status.
• Persistent variability in the quality of general practice, with a low skill base and poor organisation being widespread.
• Growing official interest in the importance of individual responsibility for health, and family and friends being seen as essential support for those in hospital.

Immediate problems:  The Health Matters seminars identified 10 problems that a Labour government elected in 2015 would need to address (but not necessarily solve) over a ten year period.

1.  Funding constraints, prompting not only smarter working but also reclassification of PFI and other historic debt as “toxic” so that it can be managed differently.
2. Generic challenges (common to all health services in industrialised societies) including social and demographic changes, system obsolescence, unwarranted variability in service performance and outcomes, increasing expectations and intolerance of poor quality, and resistance to innovation. These trends suggest that general practice and DGHs are no longer workable, as currently organised. At the least, there is need to incentivise pro-active work, particularly in Primary Care, and to change incentives for hospitals admission and discharge.
3. The separation of mental health services from other services and their fragmentation by out-sourcing. ‘Joined up care’ will remain an aspiration, and ‘integration’ will continue to be uncritically promoted as a solution  ‘Integrated care’ is an unhelpful term and is better understood as ‘joined up care’ or ‘whole person care’, or ‘co-ordinated care’, though it is not always clear what distinctions are intended. National Voice has a working definition of joined-up or integrated  care which is very patient centred.  . Joined up care is needed in the NHS, and between the NHS and social care, because: 1) patient experiences of care are so often poor; 2) it may make financial trade-offs possible and 3) it may generate efficiency savings. The NHS is good at co-ordinated care for specific time-limited activities (maternity care, surgery, rehabilitation, palliative care) but less good when care coordination is needed for high volume, complex, long-term conditions – like serious mental illness.
4. The variability of quality of care in general practice, its limited skill set and poor level of organisation, and the lack of NHS leverage over it. Although general practitioners are in theory well positioned to provide coordinated care, the discipline is unable to do so under its present contract. A new GP contract is needed which will, for example, restore responsibilities for 24 hour care to general practice.
5. The fragile means tested/privatised economy of social care, and the commonly poor working relationships between the largely commercialised care home sector and the NHS. Free social care – one option being considered  – could be funded by an Estates (Death) tax, or through  hypothecated compulsory social care insurance. Free social care could be introduced in stages. One stage could involve drawing the care home sector further into the public domain.  The different funding regimes are unhelpful, but providing social care for free will not in itself deliver more integrated services.  Further institutional instability as a result of reorganisation would be very unhelpful.  Transferring the NHS budget to local government would not only reduce the democratic deficit but also foster care coordination, but so radical a shift may not be necessary.  Making a more explicit relationship between the Health and Well-Being Boards and the NHS Trusts might be sufficient.
6. A historically weak political culture around the NHS, in which change is seen as a threat, and a deep democratic deficit, in which the public is excluded from NHS decision-making. There is a need for a mature political dialogue, but the mechanisms for it need to be established first. Community development offers participatory accountability with effective involvement in planning, usually of geographic areas.
7. Public health has been marginalised just as the social determinants of health and illness have become clearer than ever. There will be need for more emphasis on health promotion directed at all non-communicable diseases  and a radical, healthy food policy.   Community development (to increase social capital) generates early benefits for health & wellbeing, so closer working between CCGs and Health & Wellbeing Boards should be promoted . Integration is not just something that happens at the level of the individual patient.
8. NHS management has been re-organised too often, and has lost a great deal of experience and its collective memory. The decay of leadership means that the cadre of management needed not only to stabilise the NHS but also to promote organic growth within it, is weak.
9. Quality of care in the NHS is undermined by rapid and repeated organisational changes, a narrow focus on targets and the decay of leadership (amongst clinicians as well as managers). Perceptions of the quality of care will be manipulated by those hostile to the NHS.
10. Power in the NHS is dispersed across the health economy, without commensurate accountability across different centres of power, especially those in the commercial sector.

Future options:  An incoming Labour government in 2015 could centre its policy towards the NHS on a response to the generic challenges, from two angles.

First, a balanced economy of health care should contain incentives that promote prevention, health promotion and more significant strategic role for public health, reinforce holistic care, and reduce reliance on hospitals. This will probably require some combination of hospital and community services with lead commissioners and shared or programme budgets as possible funding mechanisms, but in most situations combination will not be achieved by merger. This strategy is likely to require the abolition of the Quality & Outcomes Framework in general practice, and of Payment by Results.

Second, the key attributes of a service that meets needs can be defined in terms of:

• The forward application of expertise (the most experienced in the frontline, in hospitals and community services – including out-of-hours services).
• Emphasis on the management of uncertainty at all levels of the NHS to reduce patient referral/hand-on and ‘buck passing’.
• Engagement of the public in NHS decision-making, and the NHS in community development, as a precondition for continued funding, with emphasis on increasing the power of ‘voice’ through use of social media.
• The promotion of generalism (a holistic approach) in community and hospital services.
• Making the maintenance of relational confidence between disciplines the primary task of NHS management.
• Establishing single budgets and shared financial accountability as the norm across community and hospital services, along with a single outcomes framework, and funding mechanisms aligned to desired outcomes.

In 2015 a Labour government could promote the development of local services spanning community and hospital practices, similar to Kaiser Permanente-type health maintenance organisations, but without driving their growth using market mechanisms. The exact mechanisms for governing these local services should be the subject of natural experiments (because we do not yet know the optimal mechanism), changes can occur slowly and the new services can evolve over time. Such changes could occur within existing legislation, once section 3 of the Health & Social Care Act has been repealed.

Engagement of the NHS with community development, the wider public involvement in the NHS that seems likely to occur, and the evolution of local integrated services will push the NHS towards becoming part of local as much as national government. This shift in accountability and governance will also be slow and incremental, with no system wide re-organisation by decree.